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Clin Child Fam Psychol Rev (2012) 15:144–162
DOI 10.1007/s10567-011-0109-0
Family Factors in the Development, Treatment, and Prevention
of Childhood Anxiety Disorders
Kelly L. Drake • Golda S. Ginsburg
Published online: 13 January 2012
Ó Springer Science+Business Media, LLC 2012
Abstract It is now widely accepted that anxiety disorders
run in families, and current etiological models have proposed both genetic and environmental pathways to anxiety
development. In this paper, the familial role in the development, treatment, and prevention of anxiety disorders in
children is reviewed. We focus on three anxiety disorders
in youth, namely, generalized, separation, and social anxiety as they often co-occur both at the symptom and disorder level and respond to similar treatments. We begin by
presenting an overview of a broad range of family factors
associated with anxiety disorders. Findings from these
studies have informed intervention and prevention strategies that are discussed next. Throughout the paper we shed
light on the challenges that plague this research and look
toward the future by proposing directions for much needed
study and discussing factors that may improve clinical
practice and outcomes for affected youth and their families.
Keywords Children Anxiety Family Parenting Treatment Prevention
Anxiety disorders in children are among the most common
psychiatric illnesses with prevalence rates averaging 10%
of the youth population (Costello et al. 2004, 2005; Velting
et al. 2002). These illnesses confer significant impairment
in several domains of functioning. For instance, anxious
children have academic difficulties (with under
K. L. Drake (&) G. S. Ginsburg
Division of Child and Adolescent Psychiatry,
Department of Psychiatry and Behavioral Sciences,
The Johns Hopkins University School of Medicine,
550 N. Broadway/Suite 206, Baltimore, MD 21205, USA
e-mail: [email protected]
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performance, attendance, and classroom participation),
struggle in social situations (making and maintaining
friendships), experience conflict and disruption at home
(with parents and siblings), and suffer personal distress that
negatively impacts their self-image (e.g., Greco and Morris
2004; see Muroff and Ross 2011 for a review). The mean
age of the onset of these illnesses is during early childhood
(Kessler et al. 2005). Retrospective reports from adults and
longitudinal studies of youth indicate that these disorders
are chronic and, if untreated, increase the risk for adult
anxiety, depression, substance abuse, and suicide attempts
(e.g., Beesdo et al. 2007; Bittner et al. 2007; Boden et al.
2007; Gregory et al. 2007; Pine et al. 1998). In addition to
the psychosocial impact of anxiety disorders, there is a
high economic burden with the cost of treating these disorders among adults estimated to be $42.3 billion annually
(Greenberg et al. 1999). Given the high personal and
economic burden associated with these disorders, identifying causes and effective intervention strategies are vital.
Similar to many psychiatric illnesses, anxiety disorders
run in families and etiological models of child anxiety have
identified both genetic and environmental pathways to
disease expression. This paper focuses on the familial role
in the development, treatment, and prevention of anxiety
disorders in children. Two decades of active research have
propelled the field forward, leading to new discoveries with
respect to etiology and intervention. New data are rapidly
emerging, and new technologies (e.g., fMRI and computerassisted neurocognitive assessments) are poised to produce
further breakthroughs in understanding many aspects of
child anxiety.
To identify relevant published studies for inclusion in
this review, literature searches were completed using the
PsycINFO database. Key terms related to child anxiety
(e.g., ‘‘child anxiety,’’ ‘‘child anxiety disorders,’’ ‘‘child
Clin Child Fam Psychol Rev (2012) 15:144–162
social phobia,’’ and ‘‘child social anxiety disorder’’) were
paired with key terms related to each aspect of family
environment included in this review. For example, a search
was conducted by pairing the terms ‘‘child anxiety disorder’’ with each topic (e.g., ‘‘genetics,’’ ‘‘heritability,’’
‘‘attachment,’’ ‘‘behavioral inhibition,’’ ‘‘parenting behaviors,’’ ‘‘parental control,’’ ‘‘family environment,’’ and
‘‘cohesion,’’ etc.). In addition, citations from published
review papers were cross-referenced to identify additional
papers. The full-text version of each paper was reviewed to
determine relevance. To summarize our findings, we begin
by providing a descriptive overview of a broad range of
family factors associated with the etiology and/or maintenance of anxiety disorders. Findings from these studies
have informed intervention and prevention strategies that
are discussed next. Throughout the paper, we shed light on
the challenges that plague this research, propose directions
for much needed research, and discuss the clinical implications for affected youth and their families. In contrast to
previously published papers that have reviewed the relationship between family factors and child anxiety, this
paper defines family factors more broadly (e.g., includes
sibling relations) and discusses the relevance of these
factors to both prevention and treatment.
Heritability: Anxiety Runs in Families
Family aggregation studies assessing the prevalence of
anxiety disorders in the offspring of anxious parents (i.e.,
top-down studies) or in the parents of anxious youth
(bottom-up studies) reveal higher rates compared to families in which neither child nor parent has an anxiety disorder (e.g., Biederman et al. 1991; Hudson et al. 2011; Last
et al. 1987, 1991; Livingston et al. 1985; Turner et al.
1987). For instance, Turner et al. (1987) compared the rates
of anxiety disorders in the offspring (7-12 years old) of
parents with anxiety disorders (n = 16), parents with
dysthymia (n = 14), and parents with no psychiatric disorder (n = 13). Based on diagnostic interviews, they found
that children of parents with anxiety disorders (44%) were
7 times more likely to be diagnosed with an anxiety disorder compared to children of parents with no psychiatric
disorder (8%) and twice as likely to have an anxiety disorder compared to children of parents with dysthymia
(22%). Although their sample was relatively small, the
findings are consistent with numerous studies using larger
samples.
While these studies are helpful in identifying family
aggregation, they do not explain the mechanisms by which
family influences anxiety development or the relative
contributions of genetic and environmental factors.
Examination of genetic and environmental influences
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comes from studies of twins and adoptees. Similar to the
family aggregation studies, this literature has several
methodological limitations including variations in how
anxiety was defined (e.g., fearfulness versus a diagnosis of
anxiety disorder), what specific anxiety disorders were
examined, and the measurement strategies used to assess
anxiety symptoms and diagnosis. Despite these methodological shortcomings, recent reviews (Eley and Gregory
2004; Gregory and Eley 2007) estimate that genes account
for approximately 30% of the variance in child anxiety
while shared environments (i.e., factors that are similar for
family members such as socioeconomic status) explain
approximately 20% of the variance. Non-shared environments (i.e., factors that are unique to each individual such
as peer group influences) and error explain the remaining
50% of the variance in child anxiety.
Additional research supporting the heritability of anxiety comes from studies examining the genetic basis of
temperamental, personality, and cognitive vulnerabilities
that purportedly mediate the relationship between genes
and anxiety disorders. Behavioral inhibition (BI), for
example, is a temperamental style characterized by
increased physiological arousal and fear of novel stimuli
(Kagan et al. 1984). BI is considered a risk factor for the
development of anxiety disorders (Turner et al.1996; van
Brakel et al. 2006) and has been shown to have a strong
genetic basis (Dilalla et al. 1994; Robinson et al. 1992).
Personality factors, such as neuroticism, shyness, and
emotionality, have also demonstrated a moderate to strong
genetic basis and have been linked with anxiety disorders
(Saudino et al. 2000; Thapar and McGuffin 1996). Finally,
anxiety sensitivity, which refers to beliefs that anxiety
symptoms will have devastating social, mental, or physical
consequences, has been identified as a cognitive risk factor
for the development of anxiety disorders (Reiss 1987,
1991; Reiss and McNally 1985). It is estimated that nearly
half of the variance in anxiety sensitivity is accounted for
by genes (Stein et al. 1999). These findings highlight the
complexity of anxiety genetics research and suggest that
there are multiple pathways for genes to influence phenotypic anxiety. The vulnerability factors reviewed here are
examples of indirect pathways.
The next wave of heritability studies will examine ways
in which genes and the environment interact with one
another and influence the risk pathways of anxiety development. Research that clarifies which environmental factors confer the greatest risk to children who are genetically
vulnerable (via gene-environment interactions) as well as
the mechanisms that potentiate these interactions will
enhance early detection and intervention for youth at risk.
In this vein, Lau and Pine (2008) suggest further examination of specific brain functions and neurocognitive processes such as threat bias and maladaptive information
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processing as these factors may help clarify processes
underlying gene–environment interactions. In addition,
future investigations of anxiety heritability will employ
molecular genetics to identify associations and linkages
with specific genes or gene segments. Advances in anxiety
genetics research and discoveries that will facilitate
decoding the genetic basis of anxiety disorders will produce innovative avenues for early identification, as well as
novel methods of prevention and treatment for these disorders (Eley and Gregory 2004; Smoller et al. 2009).
Nonetheless, in light of the modest genetic contribution,
etiological models of anxiety must consider other environmental factors that confer risk. Given that the family
environment is critical for children for an extended period
of time (Henderson 1980), researchers have attempted to
uncover aspects of the family that may help explain the
development of child anxiety. In the following sections, we
briefly summarize the findings, limitations, and challenges
of this literature including parent–child attachment, temperament, parenting behaviors, and family environment
characteristics that may give rise to the development and/or
maintenance of child anxiety.
Attachment and Temperament
The quality of the parent–child bond, referred to as
attachment, has been theorized to play a role in the
development of anxiety disorders. Specifically, it has been
hypothesized that insecurely attached children have greater
risk for developing anxiety disorders in general and social
anxiety specifically (Bohlin et al. 2000; Brumariu and
Kerns 2008, 2010). Theoretically, it is posited that early
experiences with unpredictable caregiver responsiveness
lead to chronic vigilance, distress, and fear of potential
abandonment, thus impacting future social relationships
(Bowlby 1973; Cassidy and Berlin 1994; Manassis et al.
1994, 1995; Shamir-Essakow et al. 2005). Numerous
studies have found that an insecure attachment is associated with elevated anxiety symptoms (Bar-Haim et al.
2007; Muris et al. 2000; Roelofs et al. 2006; van Brakel
et al. 2006) and higher rates of anxiety disorders (Manassis
et al. 1994, 1995; Warren et al. 1997). A recent metaanalysis of 46 studies reported an overall medium effect
size (r = .30) and concluded that there is a significant but
moderate relationship between an insecure attachment and
child anxiety (Colonnesi et al. 2011). In a seminal study
spanning 16 years, Warren et al. (1997) classified the
attachment style of 172 twelve-month-old infants using the
Strange Situation Procedure (Ainsworth et al. 1978). Then,
at age 17.5 years, adolescents were assessed using the
Schedule for Affective Disorders and Schizophrenia for
School-Age Children (Orvaschel et al. 1982) and classified
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as securely (57.9%), avoidantly (22.6%), or ambivalently
attached (19.5%). Results indicated that 15% (n = 26) of
the total sample of adolescents had at least one current or
past anxiety disorder. Based on attachment style, 12%
(n = 11) of those with a secure attachment, 16% (n = 6)
with an avoidant attachment, and 28% (n = 9) of those
with an ambivalent attachment developed an anxiety disorder. Furthermore, an ambivalent attachment predicted
childhood anxiety disorders even after accounting for
maternal anxiety and temperamental variables. While these
findings suggest that an insecure-ambivalent attachment
style is associated with developing an anxiety disorder, the
majority of youth classified as insecurely attached (70%)
did not develop an anxiety disorder.
Understanding the risk associated with an insecure
attachment is complicated by the co-occurrence of attachment with other predisposing factors that impact the parent–child relationship and subsequent child adjustment,
such as BI and parental psychopathology. BI has been
shown to predict anxiety symptoms over time (Mian et al.
2011) as well as anxiety disorders in general (Biederman
et al. 2001; Turner et al. 1996; van Brakel et al. 2006) and
social anxiety in particular (Biederman et al. 2001;
Chronis-Tuscano et al. 2009; Hirshfeld-Becker et al. 2007;
Muris et al. 2011). Manassis and Bradley (1994) proposed
a model of anxiety development in which temperament and
attachment equally confer risk, but the level of risk is
greater for children who have both BI and an insecure
attachment. More recently, Hudson et al. (2011) evaluated
various risk factors for child anxiety. Specifically, they
examined the relationships among child anxiety and BI,
attachment, maternal anxiety, and parenting behaviors
including overprotection, warmth, and criticism in a sample of 202 preschool-aged children (mean age = 4 years
old). Based on parent self-report and tasks rated by independent observers (IOs), findings revealed that, compared
to uninhibited children, children classified as BI were more
likely to have an anxiety disorder, an insecure (ambivalent)
attachment, and had mothers who were more likely to have
an anxiety disorder and demonstrate negative parenting
behaviors (overprotective, lacking in warmth, high in
criticism). Moreover, maternal negativity (low warmth,
high criticism) added to the prediction of child anxiety
symptoms, even after controlling for maternal anxiety and
BI, suggesting that these parenting behaviors may increase
the risk of anxiety regardless of the child’s temperamental
status. Although an insecure attachment and high levels of
parental overprotection were associated with child anxiety
diagnosis, the relative contribution of these factors to the
prediction of anxiety diminished after controlling for BI
and maternal anxiety. These findings suggests that, in
young children, BI and parenting behaviors characterized
by low levels of warmth and high levels of criticism may
Clin Child Fam Psychol Rev (2012) 15:144–162
increase the risk for developing anxiety and that BI may be
a more robust predictor of anxiety compared to attachment.
Challenges and Future Directions
Overall, the available evidence indicates that children with
BI and/or an insecure attachment may have an elevated risk
of developing an anxiety disorder, although there are mixed
findings and the relationship among these (and other) risk
factors remains poorly understood. A specific challenge to
this literature is the absence of data on the directionality of
the relationship. It is likely that child characteristics, such
as temperament, personality, or anxiety level, shape parenting behavior and the parent–child bond (Hudson et al.
2009; Moore et al. 2004; Whaley et al. 1999). Moreover,
the extent to which BI, attachment, and anxiety are unique
is also unclear—BI is associated with anxious arousal and
avoidance, and an insecure attachment is associated with
limited frustration tolerance, difficulty being soothed, and
distress when exploring the environment (Manassis
2001)—all characteristics of excessive anxiety. Despite
these challenges and limitations, signs of BI and characteristics of an insecure attachment in a child are red flags
for future risk of an anxiety disorder; thus early identification and intervention seem warranted. Indeed, there is
emerging evidence that children with BI respond to early
intervention strategies aimed at reducing anxiety symptoms
(Rapee et al. 2005) and that attachment-based treatment
strategies aimed at improving the quality of the parent–
child attachment may be effective in reducing child anxiety
(Choate et al. 2005; Siqueland et al. 2005).
Parenting Behaviors
In addition to the quality of the parent–child bond, specific
parenting behaviors have been linked to higher levels of
child anxiety. Reviews of these studies have generally
examined parents of clinically anxious youth. Among the
parenting variables examined, parental overcontrol has
shown the strongest link to the levels of child anxiety
(McLeod et al. 2007; Rapee 1997; Wood et al. 2003).
Associations between child anxiety and other parental
behaviors such as warmth and anxious modeling are mixed.
The magnitude of the relationship between parenting
behaviors and child anxiety is modest, with effect sizes
ranging from .06 to .42 and accounting for \1 to 18% of
variance in child anxiety (McLeod et al. 2007). A challenge
to synthesizing this literature has been the inconsistencies in
methodology including the ways in which parenting
behaviors have been defined and measured. Furthermore,
because most studies examining parenting behaviors failed
to account for level of parent and child anxiety
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simultaneously, the nature and direction of the relationships
among parent anxiety, child anxiety, and parenting behaviors
remain unclear. Below, we briefly review the literature on the
most commonly researched parenting behaviors and conclude with recommendations for future research.
Overcontrol
The term overcontrol has been used synonymously with
overprotection, restrictive behaviors, and behaviors that are
associated with less autonomy granting, leading to inconsistencies and confusion when interpreting findings. Nonetheless, these behaviors are believed to increase child anxiety
by restricting children’s opportunities to experience new and
challenging situations and minimizing the development of
mastery and confidence in the ability to cope with challenges.
Recent data provide at least indirect support for this theory
(Affrunti and Ginsburg 2011). Mothers of anxious, compared to non-anxious, children (regardless of maternal anxiety status) are more likely to be perceived by their children
(Bögels and van Melick 2004; McClure et al. 2001; Messer
and Beidel 1994) and IOs (Barrett et al. 2005; Edison et al.
2011; Moore et al. 2004; Siqueland et al. 1996; Whaley et al.
1999) as overcontrolling and restrictive. There is newly
emerging evidence demonstrating that parental overcontrol
predicts later anxiety symptoms in children (Edwards et al.
2010; Ginsburg et al. 2004) and anxiety disorders in adolescents/young adults (Beesdo et al. 2010). Thus, fairly
strong evidence supports the hypothesis that parental overprotection is associated with higher levels of child anxiety
(McLeod et al. 2007; Wood et al. 2003).
When subdimensions of parental overcontrol were analyzed (McLeod et al. 2007), findings revealed that lower
levels of autonomy granting and higher levels of overinvolvement explained 18% of the variance in child anxiety.
A meta-analysis by van der Bruggen et al. (2008) found
that while higher levels of child anxiety were associated
with higher levels of parental overcontrol (effect size
d = .58), a number of factors moderated this association.
Specifically, higher levels of parental overcontrol were
more strongly related to female gender for the child, higher
socioeconomic status, school-aged children, and discussion
tasks (compared to performance tasks). In contrast, parent
anxiety was not associated with overcontrol, suggesting
that parental overcontrol may be a consequence of child,
rather than parent, anxiety. This informative review was
limited to parental overcontrol. Similar analyses are needed
for other key parenting behaviors.
Parental Warmth
Parental warmth refers to verbal and non-verbal behaviors that
demonstrate positive affect, affection, and acceptance of the
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child. Children of parents who do not attend to their emotional
needs may lack a sense of support and affiliation that may
increase anxiety. Overall, the evidence supporting the association between parental warmth and anxiety is modest and
inconsistent (McLeod et al. 2007; Wood et al. 2003). In fact,
McLeod and colleagues (2007) determined that parental
warmth was weakly associated with child anxiety and
explained less than 1% of variance in anxiety across studies.
Inconsistent findings may be due to variability across informants. In one study that included multiple informants,
Siqueland et al. (1996) obtained child, parent, and IO ratings
of parental warmth in a sample of anxious (n = 17) and nonanxious (n = 27) children and their parents. Anxious children
described their parents as significantly less warm, compared to
non-anxious children; however, no differences were detected
based on parent report or IO ratings. It is possible that anxious
children may have a distorted or negative view of their parents, reflecting a reporting bias. Nonetheless, others have
reported that parents of children with anxiety disorders were
less warm based on IO ratings (Hudson et al. 2011; Hudson
and Rapee 2001), and for others, this relationship was only
apparent when both the parent and child were anxious
(Whaley et al. 1999). The reciprocal relationships among
parent and child characteristics and warmth require further
exploration; however, in light of the overall modest effect,
other parenting and family factors should be evaluated as they
may be more robust predictors of child anxiety.
Criticism and Rejection
Parental criticism and rejection refer to behaviors that are
overly hostile, disapproving, and dismissing of the child. It
is hypothesized that parental criticism and rejection negatively impact the child by increasing parent–child conflict,
reducing a child’s sense of self-competence and self-worth,
and ultimately increasing the child’s level of anxiety
(Ginsburg and Schlossberg 2002; Rapee 1997). Indeed,
several studies have found that higher levels of parental
criticism and rejection are associated with anxiety disorders (Hudson et al. 2011; Lieb et al. 2000) as well as higher
levels of anxiety symptoms based on child report (Lieb
et al. 2000), parent report (Hibbs et al. 1993), and IO ratings (Dumas et al. 1995; Festa and Ginsburg 2011; Hudson
and Rapee 2001). Furthermore, in a longitudinal study,
Ginsburg et al. (2004) found that IO ratings of maternal
criticism predicted higher levels of child anxiety symptoms
6 years later. This was true for anxious, but not non-anxious, mothers—a finding which highlights the need to
assess anxiety in parents and children. Overall, however,
reviews have concluded that the association between
parental criticism/rejection and child anxiety is relatively
small, accounting for only 4% of the variance in child
anxiety (McLeod et al. 2007; Wood et al. 2003).
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Anxious Modeling
Parental anxious modeling refers to a parent’s tendency to
demonstrate anxious thoughts, feelings, or avoidant
behaviors in front of the child. It is theorized that parents
who model anxious behaviors may inadvertently teach
their children to be anxious and avoidant (Beidel and
Turner 1997; Bögels and Brechman-Toussaint 2006; Capps
et al. 1996; Fisak and Grills-Taquechel 2007; Rapee 2002).
Correlational studies demonstrate a positive relationship
between parent-reported modeling of anxious behavior and
child-reported fears (Muris et al. 1996) as well as positive
correlations between child reports of parental modeling and
anxiety symptoms in non-clinically anxious children
(Grüner et al. 1999; Muris and Merckelbach 1998; Roelofs
et al. 2006; van Brakel et al. 2006). However, results are
mixed, and there are considerable inconsistencies across
studies, making it difficult to ascertain the magnitude of the
association between parental modeling and child anxiety
(see Fisak and Grills-Taquechel 2007 and Wood et al. 2003
for reviews). Nonetheless, some hypothesize that parents
who model social inactivity/withdrawal in particular (perhaps due to their own desire to avoid social anxiety-provoking situations) may inadvertently increase social
anxiety and avoidance in their children. Indeed, several
studies have demonstrated that, compared to normal children, youth with social phobia report lower levels of family
sociability (Bögels et al. 2001; Caster et al. 1999; Johnson
et al. 2005). It is possible that children growing up in a
socially isolated environment have limited opportunities to
habituate to social interactions and to develop a sense of
competence and mastery, thereby increasing their level of
social anxiety (Fisak and Grills-Taquechel 2007). Recent
findings also suggest that children with social difficulties
(i.e., poor friendship quality and deficient social skills) are
at greater risk for peer victimization that could further
increase anxiety (Crawford and Manassis 2011).
In addition, higher levels of parent anxious communication
are associated with child anxiety disorders (Barrett et al. 1996;
Chorpita et al. 1996; Dadds et al. 1996; Shortt et al. 2001). One
form of anxious communication that has received much
empirical attention is parent–child transmission of threat bias
when interpreting ambiguous stimuli. It is well established
that anxious, compared to non-anxious, children are more
likely to interpret ambiguous situations as threatening (Barrett
et al. 1996; Bögels et al. 2003; Cannon and Weems 2010;
Chorpita et al. 1996; Hadwin et al. 2006; Waters et al. 2008).
Early investigations suggested that parents may play a role in
the development of children’s threat bias by modeling, via
verbal and non-verbal communication, their own threat biases
and avoidant tendencies (Barrett et al. 1996; Chorpita et al.
1996). For instance, using an experimental design, Barrett
et al. (1996) presented clinically anxious and non-anxious
Clin Child Fam Psychol Rev (2012) 15:144–162
children with ambiguous situations and asked them to provide
an interpretation and response solution for each situation. Two
situations were selected for family discussions, following
which children were asked for their final solution. Compared
to their non-anxious counterparts, anxious children perceived
ambiguous situations as more threatening and demonstrated a
strong preference for avoidant responses. Furthermore, for
anxious children, avoidant responses dramatically increased
following family discussion, and their parents were more
likely to reward and reciprocate avoidant responses (Dadds
et al. 1996). Recent findings suggest that parental level of
anxiety may explain the positive correlations between parent
and child threat bias (Lester et al. 2009). Although others have
not found support for the hypothesis that family discussion
enhanced children’s preference for avoidant responses
(Bögels et al. 2003; Cobham et al. 1999), overall findings
suggest that aspects of parent–child communication may play
a role in the transmission of threat bias (and subsequent anxiety) from parent to child. Taken together, this research provides some evidence that children may emulate the anxious
behaviors and cognitions they observe in their parents.
Given that the extant literature is largely correlational,
conclusions regarding the causality between parental modeling and child anxiety cannot be made. Of the few studies that
have employed an experimental approach, infants and toddlers have been the focus. For example, de Rosnay et al.
(2006) found that infant responses to a stranger mirrored the
behavior of their mothers such that infants demonstrated more
fear and avoidance of the stranger when their mother had
previously shown fearful (as opposed to friendly or neutral)
behavior toward the stranger. Similarly, Gerull and Rapee
(2002) found that toddlers demonstrated more fear and
avoidance of stimuli that were paired with a negative (rather
than a neutral or positive) maternal facial expression. In the
one study that included school-aged children (8–12 years
old), Burstein and Ginsburg (2010) randomly assigned healthy child–parent dyads (N = 25) to two experimental conditions: an anxiety-provoking condition in which parents
behaved anxiously before the child completed a spelling test
and a non-anxiety-provoking condition in which parents
behaved relaxed and confident before the spelling test. Findings revealed that children reported higher levels of anxiety
and an increased desire to avoid the spelling test when parents
expressed anxiety. Although replication with larger and
clinically anxious samples is necessary, results from the extant
experimental studies suggest that parents may directly impact
the development of child anxiety by modeling such behavior.
Parental Cognitions
A primary feature of anxiety disorders in childhood is the
presence of cognitive distortions, including negative self-
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evaluations. A number of studies have supported a link
between parental cognitions and child negative self-evaluations and anxiety. Specifically, parent’s negative beliefs
about their child’s disposition, coping ability, and potential
for success have been linked with children’s low expectations for successful coping and higher levels of anxiety
symptoms (Wheatcroft and Creswell 2007) and disorders
(Kortlander et al. 1997). Studies have further demonstrated
that parents of children with anxiety disorders report more
negative expectations of their child’s ability (skill, coping
ability, and/or likelihood of experiencing distress) than do
parents of non-anxious children (e.g., Barrett et al. 1996;
Kortlander et al. 1997; Micco and Ehrenreich 2008; Shortt
et al. 2001). Although maternal negative expectations predict higher levels of child anxious cognitions concurrently
(Micco and Ehrenreich 2008) and over time (Creswell et al.
2006), the magnitude of these associations and the mechanisms by which parental cognitions influence child anxiety
are poorly understood. Emerging evidence suggests that
parental cognitions, characterized by beliefs that child anxiety symptoms are harmful, may mediate the relationship
between parent and child anxiety (Francis and Chorpita
2011); however, the influence of these beliefs on parent
behavior has not been assessed. Kortlander et al. (1997)
hypothesized that when anxious children demonstrate difficulties with coping, their parents may learn to expect poor
coping in the future regardless of child behavior and attempt
to prevent distress by engaging in overprotective or overcontrolling behaviors. Such parenting behaviors may
unwittingly decrease children’s opportunities to learn how to
cope with challenges, reduce their overall sense of selfefficacy, and increase anxiety. Becker and Ginsburg (2011)
found that anxious, compared to non-anxious, mothers were
more likely to expect their child to experience distress during
a social-evaluative task. However, maternal expectations did
not predict child distress, coping, or performance during the
task. On the other hand, children’s negative self-evaluations
were associated with maternal overcontrol and anxious
behaviors, suggesting that maternal expectations/cognition
may play a role in child anxiety but only when they are
conveyed to the child verbally or behaviorally. Additional
studies that directly test this hypothesis are needed to shed
light on the relationship between parental expectations,
behavior, and child anxiety.
Parental Anxiety and Parenting Behavior
Because of the high rate of anxiety disorders in the offspring of anxious parents and the hypothesis that anxious
parents may be more susceptible to parenting stress,
thereby increasing their use of ‘‘anxiety-enhancing’’ parenting behaviors, a number of researchers have examined
the behavior of anxious parents in relation to child anxiety
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(Grüner et al. 1999; Lieb et al. 2000). In general, these
studies provide only limited support for the claim that
anxious, compared to non-anxious, parents tend to be
overcontrolling, less warm, and model more anxious
behavior (Bögels and Brechman-Toussaint 2006; Drake
and Ginsburg 2011; Grüner et al. 1999; Wood et al. 2003).
Indeed, although parental anxiety may influence parenting
behaviors in some cases, there is emerging empirical evidence that higher levels of child anxiety evoke certain
parenting behaviors (Hudson et al. 2009; Moore et al.
2004; Whaley et al. 1999). Future studies are needed to
clarify the role of child anxiety in shaping parental
behavior.
the family structure, the nature of relationships within the
family, and how the family copes with stressors. Few
studies have directly examined the relationship between
dimensions of family environment and child anxiety. Of
the studies that have been conducted, there is some evidence that certain family factors may be associated with
higher levels of child anxiety; however, these findings are
inconsistent across studies, and the magnitude of these
associations is unclear. Nonetheless, there are a few
dimensions of family environment that have been proposed
as potential factors associated with the development of
child anxiety that warrant further study, and these are
discussed below.
Challenges and Future Directions
Cohesion
Methodological variations across studies in terms of
informant, measurement technology, child and parent
characteristics (e.g., diagnostic status), as well as a lack of
consensus regarding definitions of key parenting constructs, present challenges for the study of parenting
behaviors and child anxiety. To address these challenges,
definitions of key constructs need to be operationalized and
paired with reliable measurement techniques that can be
administered to multiple informants in order to standardize
the behaviors under investigation and obtain data from
multiple sources. A theoretically based and empirically
derived system of assessing a broad range of well-defined
parenting constructs across multiple informants using
multiple methods would enhance the existing nomenclature
and facilitate replication. In addition, future studies will
need to examine a wider array of parenting behaviors such
as intrusiveness, disciplinary practices, and coercive patterns of parent–child interaction. The interaction among
parenting behaviors has yet to be explored, and to date, the
majority of studies have examined mothers and not fathers,
though a small body of this literature is emerging (Bögels
and Phares 2008; Bögels and van Melick 2004; Hudson and
Rapee 2002). Additional studies employing a prospective
design with moderator/mediator analyses are needed to
assess the direction of effects, the impact of parenting
behaviors at critical developmental time periods, and the
mechanisms by which these behaviors may influence child
anxiety.
Family cohesion refers to the extent of interconnectedness
and affiliation among family members. Extremes of cohesion in either direction are theorized to be problematic for
child development. Specifically, very low cohesion reflects
estranged, emotionally disconnected relationships, and
children raised in such disengaged families may experience
a lack of support and warmth which could increase child
anxiety. Alternatively, very high cohesion, which is characterized by fused and enmeshed family relationships
(Bowen 1978; Peleg-Popko and Dar 2001), may also
increase child anxiety because enmeshed families are
associated with higher levels of parental overprotection and
limited opportunities for children to experience challenges
and develop coping skills (Barber and Buehler 1996).
Studies have found that parents’ reports of low (Stark et al.
1990) and high (Peleg-Popko and Dar 2001; Teichman and
Ziv 1998) levels of cohesion were related to child anxiety
symptoms, general fearfulness, social avoidance, and fear
of negative evaluation in community samples of youth.
These findings, however, were not replicated with samples
of clinically anxious youth (Messer and Beidel 1994), and
studies have not assessed family cohesion using IO ratings
or prospective designs, making it difficult to assess the
relative impact of cohesion on child anxiety development.
Future studies are needed to refine current definitions of
key constructs (e.g., cohesion, warmth, and overprotection)
to ensure that they are sufficiently distinct and to clarify the
role, if any, that family cohesion plays in the development
of child anxiety.
Family Environment
Adaptability
In addition to the parenting behaviors reviewed above,
specific characteristics of the family environment have
been explored in relation to the development and/or
maintenance of child anxiety. These characteristics include
a broad range of dimensions that reflect the functioning of
Adaptability is defined as the degree of flexibility with
respect to familial roles and the existing power structure in
response to stressors (Peleg-Popko and Dar 2001). Families
vary in the extent to which there is flexibility in the
adherence to family member’s roles, family rules, and the
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consequences of rule violations. Extremes in either direction are associated with negative outcomes for children. On
one hand, very high levels of adaptability indicate a lack of
rules and chaotic family interactions (Ben-David and Jurich 1993), which may give rise to uncertainty concerning
caregiver responsiveness (Barber and Buehler 1996) and
increase child anxiety. Indeed, such family environments
have been associated with higher levels of child anxiety
symptoms (Teichman and Ziv 1998). On the other hand,
very low levels of adaptability are associated with overly
strict adherence to rules and rigidity and have been linked
with excessive parental overcontrol (Barber and Buehler
1996). As mentioned earlier, children raised in overcontrolling households may have fewer opportunities to exercise independence and develop a sense of mastery and
competence, leading to higher levels of anxiety. Although
few studies have directly tested this assumption, there is
some evidence that children raised in families with very
low levels of adaptability report higher levels of fearfulness
and anxiety symptoms (Bernstein et al. 1999; Peleg-Popko
and Dar 2001). Taken together, there is some evidence that
extremes of family adaptability (high or low) are associated
with child anxiety symptoms. However, additional studies
using clinically anxious samples and prospective designs
are needed to clarify the role of adaptability with respect to
the development of anxiety disorders.
Conflict
Family conflict refers to disagreements among family
members that potentially increase child anxiety by increasing tension and straining the parent–child relationship.
Higher levels of family conflict have been associated with
higher levels of child anxiety symptoms based on child
(Messer and Beidel 1994) and parent report (Stark et al.
1990). Prospective studies of this relationship are rare;
however, one retrospective study found that higher levels of
conflict during childhood predicted anxiety symptoms during adulthood (Rekart et al. 2007). This association was
modest and only true for females. Furthermore, there was
evidence that the relationship between conflict and anxiety
was, in large part, accounted for by a pessimistic cognitive
style (Rekart et al. 2007). It may be that other factors help
explain or moderate the association between conflict and
anxiety. For instance, parenting stress (van Oort et al. 2010),
deficient problem solving skills (Hughes et al. 2008), or
conflict in the marital relationship (Nomura et al. 2002) may
increase conflict and subsequent child anxiety.
Marital Relationship
While a thorough review of the effects of marital/interparental conflict and related consequences such as
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interparental violence, separation, and divorce is beyond
the scope of this paper, these constructs have been linked to
internalizing (and externalizing) disorders and symptoms
in children (see Hudson 2005 for a review) and are briefly
reviewed next. Empirical research examining the relation
between marital conflict and child anxiety disorders specifically is limited and contradictory. For instance, one
study found no differences in self-reports of marital quality
between parents of children with anxiety disorders and a
normal control group (Siqueland et al. 1996). In contrast, as
part of a large 10-year longitudinal study, Nomura et al.
(2002) found that poor marital adjustment (among the
sample of non-depressed parents only) was associated with
a fourfold increase in child anxiety disorders, even after
controlling for child age and gender. However, in this
study, marital discord was also associated with an
increased risk for depressive and substance use disorders,
raising questions about the specificity of this relation.
A more substantial literature, based on non-clinical
community samples, has consistently shown that higher
levels of interparental conflict is associated with higher
levels of child anxiety symptoms (Bögels and BrechmanToussaint 2006; Cummings 1994; Cummings et al. 2003;
Tanaka et al. 2010). Longitudinal studies also indicate that
both low marital satisfaction and high interparental conflict
predict anxiety symptoms over time (Howes and Markman
1989; Jekielek 1998; McHale and Rasmussen 1998;
Mechanic and Hansell 1989). For instance, McHale and
Rasmussen (1998) reported that marital conflict at age 1
predicted teacher’s reports of the child’s anxiety at age
4 years.
An extension of marital conflict is maladaptive co-parenting among separated or divorced parents. Co-parenting
behaviors can be positive and supportive (e.g., complimenting or praising the co-parent in front of the child when
co-parent is present and absent) or negative (withdrawal,
criticism, or hostility toward the co-parent). In studies
examining this construct (e.g., Katz and Low 2004,
McHale and Rasmussen 1998), negative co-parenting has
been associated with higher symptoms of child anxiety
(and other forms of psychopathology). Relatedly, in one of
the larger studies in this field, Jekielek (1998) demonstrated
that the strongest and most consistent predictor of later
anxiety was exposure to ongoing marital conflict rather
than divorce, suggesting that living with or being exposed
to high levels of conflict in the co-parenting relationship
likely increases the risk of developing excessive anxiety
during childhood.
Several theories have been proposed to explain the
mechanisms by which interparental conflict impacts child
anxiety (e.g., Emery 1989). Data from various bodies of
literature supports the hypothesis that interparental conflict
negatively impacts parenting practices (e.g., greater
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inconsistency, hostility), which in turn, negatively impacts
child adjustment (e.g., Doyle and Markiewicz 2005). In the
context of marital conflict, parental modeling of anxiety,
withdrawal, poor coping, and maladaptive conflict resolution strategies have also been linked to child internalizing
symptoms (e.g., Dadds et al. 1999). Data also support the
notion that the impact of interparental conflict depends
largely on child appraisals of the conflict. Specifically, the
more children blame themselves for the conflict or perceive
the conflict to be uncontrollable, unpredictable, threatening, and/or likely to lead to abandonment or danger, the
more likely they are to experience symptoms of anxiety
(Dadds et al. 1999; Grych et al. 2000; Jouriles et al. 2000).
Increased interparental conflict is also believed to disrupt
the quality of the parent–child bond leading to greater child
insecurity and anxiety.
Taken together, while there are much data to support
various mechanistic models, most studies are limited in
that they do not control for genetics (i.e., heritability),
parental or child premorbid psychopathology, or a host of
other factors that may account for these relations. Moreover, the magnitude of the relation between interparental
conflict and child anxiety is difficult to determine given the
variations in methodologies used across studies. One early
estimate, based on a meta-analysis, estimated the effect
size of interparental conflict on child internalizing symptoms to be .31 (Buehler et al. 1997). However, the impact
of interparental conflict also appears to vary by a number of
factors including parents’ use of conflict resolution styles
(Cummings et al. 2003), the chronicity of the conflict
(Cummings et al. 1989), and numerous child factors (e.g.,
age, gender, temperament, and cognitive appraisals). Thus,
research elucidating the complex and reciprocal relations
between marital conflict and child anxiety disorders is still
needed.
Sibling Relationships
Sibling relationships are often long-lasting and intense
relationships, having important developmental implications
for one’s social, emotional, and behavioral adjustment
(Buhrmester et al. 1992; Dunn et al. 1994a, b; Stocker
1994; Volling 2003). Problems in the sibling relationship,
especially those characterized by hostility, conflict, and
control, are associated with higher levels of child anxiety.
The mechanisms underlying this association are unclear
but likely to be multi-determined. For instance, it may be
that the anxious child’s avoidance and related symptoms
lead to difficulties in the sibling relationship (e.g., greater
conflict, lower warmth). Alternatively, sibling jealousy and
parental preference toward the anxious child may enhance
hostility and conflict between siblings. Evidence from
cross-sectional (Fox et al. 2002) and longitudinal (Kim
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et al. 2007; Stocker et al. 2002) studies show that sibling
relationship quality—that is, levels of intimacy, warmth,
control, and/or conflict—is associated with children’s
internalizing problems including anxiety symptoms.
Importantly, the association between sibling relationship
quality and internalizing problems remains even after
controlling for other influential factors such as marital
conflict and maternal hostility (Stocker et al. 2002).
Impaired sibling relationships are also associated with
clinical levels of anxiety. In one study of 51 clinically
anxious children and their sibling, researchers found that
their interactions, relative to non-anxious healthy control
sibling dyads, were characterized by higher levels of selfreported conflict, more observed control by both children,
and less warmth from the anxious child (Fox et al. 2002).
Children with anxiety disorders have also been found to
report their siblings receive more parental preferential
treatment (e.g., views parent as unfair in how they are
treated compared to sibling, jealous about how much
affection or attention sibling receives) than their non-anxious siblings (Lindhout et al. 2003, 2009), which may
impair the quality of the sibling relationship perhaps due to
jealousy and real or perceived deficits in parental attention.
Taken together, there is evidence that the sibling relationship is associated with childhood internalizing problems
across a broad range of severity, although the magnitude of
this association and the implications for treatment require
further investigation.
Challenges and Future Directions
The majority of studies examining the relationships among
various family environmental factors and child anxiety
have been cross-sectional, relied on the perspective of a
single individual (usually a parent), and failed to include
observational paradigms. Thus, findings have not been
replicated across multiple informants or over time. Also, as
highlighted in the preceding section, there is a lack of
consistency in how key concepts are defined and measured.
Finally, few studies have controlled for the influence of
parent anxiety symptoms. This is especially important
given findings from a recent study, which suggest that
higher levels of parental anxiety symptoms were associated
with more negative perceptions of general family environment (Hughes et al. 2008). All of these factors make it
difficult to draw definitive conclusions regarding the significance of family environment in the development of
child anxiety. A further challenge is disentangling the
relationship between child anxiety and family functioning
when comorbidities are present. It is well documented that
children with anxiety disorders have high rates of comorbid
anxiety disorders, depression, conduct disorder, oppositional defiant disorder, attention deficit hyperactivity
Clin Child Fam Psychol Rev (2012) 15:144–162
disorder (ADHD) (Angold et al. 1999; Costello et al. 2005;
Jarrett and Ollendick 2008; Kovacs and Devlin 1998),
learning disabilities (Sundheim and Voeller 2004), and
medical illnesses (Chavira et al. 2008). Although the
presence of comorbid conditions has been shown to contribute to higher levels of symptom severity, somatic
complaints, and functional impairment relative to children
without comorbidities (Chavira et al. 2008; Guberman and
Manassis 2011; O’Neil et al. 2010), little is known about
how co-occurring conditions impact the family environment or the parent–child relationship. Recently, however, a
few studies have reported increased disruption in families
of children with anxiety plus comorbid disorders. For
instance, parents of children with anxiety disorders and
medical comorbidities, compared to those without comorbidities, reported higher levels of caregiver strain (Chavira
et al. 2008); children with comorbid anxiety and depressive
disorders report greater family dysfunction and problematic affective responsiveness compared to children with
anxiety disorders alone (Guberman and Manassis 2011;
O’Neil et al. 2010), and families with children who have
anxiety disorders and ADHD have been characterized as
having higher levels of overprotection, overcontrol, and
conflict and lower levels of cohesion compared to families
without comorbidities (Kepley and Ostrander 2007;
Pfiffner and McBurnett 2006). Future studies are needed to
assess the impact of psychiatric and medical comorbidities
and determine the direction of the impact (i.e., whether
children reared in dysfunctional families have a greater risk
for developing comorbid conditions or whether family
functioning suffers in response to children who are more
impaired due to having multiple conditions).
Although additional studies examining the impact of
parenting behaviors and family environment, including
sibling and marital relationships, on child anxiety are
needed, a growing body of research has examined the role
of the family in treatment. Findings from this literature are
reviewed below.
Family Involvement in Treatment
Evidenced-based psychosocial treatments for child anxiety
are based on cognitive behavioral therapy (CBT; see
Silverman and Pina 2008 and Silverman et al. 2008 for
reviews). The core components of CBT include psychoeducation, gradual in vivo exposure, cognitive restructuring, relaxation skills, and relapse prevention. Initial studies
of CBT for anxiety disorders in children were childfocused (Kendall 1994). However, clinical observations of
parent–child interactions, emerging data on the role of
parents in the etiology and maintenance of anxiety, and the
modest effect sizes of child-focused CBT prompted
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numerous efforts to involve parents more centrally in the
therapy of anxious youth (Ginsburg et al. 1995). In this
section, we describe the common elements of treatments
that involve parents (referred to hereafter as family-based
CBT or FCBT), present the evidence for the efficacy of
FCBT, and discuss what family or parenting factors have
been found to predict treatment response. We conclude
with a critique of this literature, outline the challenges of
this work, and present ideas for future research.
Components of Family-based CBT
To enhance treatment outcome for children with anxiety
disorders by including parents more centrally, several
adjustments were made to existing CBT protocols. The most
common elements of FCBT (i.e., the skills taught directly to
parents) for anxiety include: psychoeducation, contingency
management, parent anxiety management (i.e., strategies for
lowering parents’ anxious and avoidant behavior and dysfunctional beliefs), problem-solving skills, and relapse prevention. These components are described below.
Psychoeducation
Psychoeducation with parents involves presenting facts
about anxiety and its disorders such as key signs and
causes. This information helps clarify for parents what is,
and is not, anxiety and helps them identify which behaviors
will be the focus of treatment for their child. Parents are
taught that anxiety disorders are multi-determined (i.e.,
caused by both biological and environmental factors) and
not usually caused by one specific event. Psychoeducation
for parents also involves providing an overview of the
treatment program (i.e., FCBT model, rationale, and goals).
Describing the FCBT model lets parents know what
treatment will involve for them (and their child) and what
they will need to do to help reduce their child’s anxiety.
When psychoeducation is done effectively, it instills hope
and increases motivation. Most FCBT approaches describe
the treatment model using a ‘‘team’’ metaphor in which the
child, parent, and therapist are all working together, and the
therapist is like a coach, teaching new skills, providing
weekly assignments for parents and children to practise at
home, and outlining the specific roles parents are expected
to play.
Psychoeducation for parents may also include a
description of specific parenting behaviors that maintain or
increase anxiety in children (e.g., overcontrol, criticism,
and anxious modeling). In our work, we refer to these
behaviors as ‘‘parenting slips’’ and help parents identify
whether they are present in their family and if so, we
provide instruction on how to replace these behaviors with
more helpful parental responses (e.g., encouraging child
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autonomy and facing fears, setting realistic expectations,
and modeling coping behavior). We emphasize that most
parents do what they think is in their child’s best interest
(e.g., allowing a child with social anxiety to avoid a party
with their peers). However, it is explained that parents’
good intentions (e.g., parent speaking to a teacher because
child is too shy to do so) can actually maintain or increase
the child’s anxiety level in the long run. Parents are then
provided with instructions for changing parent behaviors
that promote anxiety into behaviors that promote effective
coping with anxiety.
Contingency Management
The basic principles of contingency management (CM) are
based on operant learning theory. Simply stated, parents
are taught that behaviors (including anxious, avoidant
behaviors) are controlled by their consequences and that
behaviors generally increase in frequency when followed
by something positive (a reinforcer) and decrease in frequency when they are not reinforced. CM involves
instructing parents to reward brave behavior and ‘‘ignore’’
(not reward or reinforce) anxious and avoidant behaviors.
This helps parents shift their attention away from the
child’s anxious behaviors and toward their mastery of
anxiety-provoking situations. To facilitate follow through
with CM, parents and children create a list of different
types of reinforcers (e.g., activities, social or tangible prizes) that are earned for demonstrating brave behavior and
coping with anxiety. Parents can use written contracts to
implement this reward system at home to reinforce children’s brave behavior and extinguish anxious, avoidant
behavior.
Parent Anxiety Management
As noted earlier, a significant proportion of parents with
anxious youth struggle with their own anxiety (Biederman
et al. 1997). This anxiety may be manifested in avoidant
behavior (e.g., parent does not drive or use the phone) and
distorted cognitions about the world (e.g., thinking all
restaurants are unsafe) or their child (e.g., ‘‘my child is too
frightened to attend this party, so it would be better for him
to stay home’’). Thus, several FCBT treatment studies view
parents as co-clients in therapy (Kendall et al. 2000). In
these situations parents are encouraged to use the CBT
skills being taught to their child, including exposure,
relaxation skills, cognitive restructuring, etc. Perhaps most
important is that parents are coached on how to be a
‘‘coping model’’ who faces, rather than avoids, their fears
despite feeling anxious.
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Problem-solving
Another common element of FCBT is problem-solving
skills. This skill encourages parents (and children) to develop
a plan for coping with their anxiety (i.e., what the child and
parent can do to make the situation less anxiety provoking so
that they can complete exposures and engage in more
effective coping) and solve other problems that may increase
stress and anxiety (e.g., conflict). The steps to problemsolving are similar across treatments (based on the work of
D’Zurilla and Goldfried 1971). In our own clinical work, we
rely on the SOLVE acronym, where each letter stands for a
specific problem-solving step. The steps of this problemsolving method are as follows: (1) Settle down (it is better to
try to solve problems when you are calm), (2) Own the
problem (identify the part of the problem that is under your
control), (3) List solutions (brainstorm solutions without
judging them), (4) Vote for one solution (after listing the pros
and cons of each one), and (5) Engage in a solution (choosing
the one that seems best, evaluate the outcomes, and repeat, if
needed). Given that family conflict (e.g., fights with siblings,
parents) often contributes to increased levels of anxiety,
parents and children are encouraged to use the SOLVE steps
to help resolve disagreements among family members.
Relapse Prevention
The goal of relapse prevention is to teach children and
parents to anticipate recurrences of anxiety and develop
plans for effective coping in order to prevent a full relapse
of anxiety. Critical aspects of this component of treatment
involve normalizing recurrences of anxious and avoidant
behavior and encouraging parents to be proactive rather
than reactive. Because parents’ response to relapses can
influence how quickly children ‘‘get back on track,’’
treatment emphasizes that parents do not react with disappointment, criticism, or anger when the child experiences distress and/or wishes to avoid a previously
conquered situation. Empathy and understanding in addition to maintaining the use and ongoing practice of the core
elements of FCBT are accentuated. Some discussion of
triggers, an action plan to manage the relapse, and planning
ahead are incorporated in this component.
Efficacy of Family-based CBT
Over 15 randomized controlled trials (RCTs) have evaluated a FCBT for anxiety disorders in youth. The specific
skills taught to parents varied across studies as did the
number of sessions that included parents in the treatment
and the format of treatment delivery (group, individual, and
dyadic). Despite these differences, effect sizes of FCBT
compared to waitlist (WL) were medium to large with
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respect to anxiety reduction (see Barmish and Kendall 2005
for a review). These findings suggest that FCBT is efficacious for the majority of youth who receive them. However,
when FCBT has been compared to child-focused CBT,
results have been mixed with some studies showing that
FCBT was superior (e.g., Spence et al. 2000; Wood 2006),
others showing no differences between FCBT and childfocused CBT (Kendall et al. 2008; Nauta et al. 2003; Suveg
et al. 2009), and at least one study showing that child-focused
CBT was superior to FCBT (Bodden et al. 2008). Thus, the
added benefit of FCBT over child-focused treatment remains
unclear (see Barmish and Kendall 2005; Creswell and
Cartwright-Hatton 2007; In-Albon and Schneider 2006;
James et al. 2005 for reviews). The uncertainty about the
added benefits of parental involvement in treatment may in
part be due to methodological limitations, such as the small
sample sizes and restricted statistical power used in these
studies that compare two active and potent treatments.
Moreover, it may be that family-based treatments are more
effective depending on specific child or family characteristics such as child gender, parental psychopathology, or levels
of family dysfunction. This conclusion was echoed in one of
the few reviews of family-based treatments for youth with
anxiety disorders conducted by Barmish and Kendall (2005).
In this study, the authors evaluated nine CBT treatment
outcome trials with anxious youth that included parents in
the treatment. They concluded that current evidence does not
yet support the notion that a family-based treatment (or a
treatment that includes parents) is superior to a child-focused
treatment. They highlight the need for large randomized
controlled trials that address the wide variations in previous
studies (e.g., number, content, format of parent and child
sessions, and outcome measures) and testing theoretical
models that underlie the reasons and methods for involving
parents in their child’s treatment. The authors also emphasize that the benefit of including parents in treatment may
vary depending on child age (and perhaps diagnosis).
An equally important question in whether we need to
routinely include parents in child treatment is whether there
are benefits to the use of parent only treatments. For
instance, a study by Waters et al. (2009) compared the
efficacy of a 10-week-group CBT treatment delivered to
either parents alone, both children and parents, or a waitlist control. Findings revealed that children in both active
treatment conditions showed superior outcomes relative to
the wait-list condition; however, there were no differences
between the two active treatments. Specifically, approximately 55% of children in both active treatments no longer
met criteria for their principal diagnosis at post-treatment,
and the treatment gains were maintained in both treatment
conditions at 6- and 12-month follow-up assessments.
These finding are consistent with other studies that have
shown that parent only treatments for childhood anxiety are
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efficacious (Cartwright-Hatton et al. 2005; Mendlowitz
et al. 1999; Thienemann et al. 2006) and highlight the need
to explore this alternative treatment model and determine
that families might benefit most from a parent only
approach to treatment.
Parental and Family Predictors of Treatment
Examining familial and parental predictors or moderators
of treatment response present the opportunity to personalize treatment and improve outcomes by targeting those
factors that either reduce or enhance treatment response.
One of the most frequently examined predictors has been
parental (generally maternal) anxiety. Several studies have
found that higher levels of parent anxiety symptoms or
parental anxiety disorder predicted poorer treatment outcomes (Berman et al. 2000; Bodden et al. 2008; Crawford
and Manassis 2001; Kendall et al. 2008; Southam-Gerow
et al. 2001). However, this finding has not been consistent
(Ginsburg et al. 2011; Wood et al. 2003). Alternatively,
parental anxiety might moderate treatment response. For
instance, some studies have demonstrated that anxious
children with anxious parents benefited more from CBT
that included parent anxiety management than from childfocused CBT with no parental involvement (Cobham et al.
1998; Kendall et al. 2008).
Other parental symptoms of psychopathology have been
examined in relation to child anxiety treatment response.
Southam-Gerow et al. (2001) found that higher levels of
maternal-reported depressive symptoms were associated
with poorer treatment response. Berman et al. (2000) found
that higher levels of a broad range of parental symptoms
including obsessive compulsive, psychoticism, depression,
hostility, paranoia, and fear all predicted poorer treatment
response. Again, elevated symptoms of psychopathology in
parents have not uniformly been linked with poor treatment
response (Rapee 2000). Parental psychopathology may also
affect other aspects of the family environment or parent–
child relationship that impact treatment response. For
instance, Crawford and Manassis (2001) found that overall
family dysfunction, parenting stress, and the frequency of
parents becoming angry, critical, or irritable with their child
predicted poorer treatment response. Future studies are
needed to examine additional family and parental characteristics that influence treatment outcome as well as the
mechanisms by which outcomes are affected. Toward this
end, interventions can be enhanced by targeting malleable
family factors that promote or hinder treatment response.
Challenges and Future Directions
Inconsistencies afflict the literature on family-based treatment for child anxiety disorders. Methodological
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limitations such as small sample sizes, which limit statistical power, variations in the type of treatment components
and delivery modality, differing sample characteristics
(e.g., age, gender, and presence of comorbid disorders), and
outcome measures used to assess parenting/family factors
make synthesizing this literature challenging. The next
wave of clinical trials should incorporate design features
that address these issues and also examine mechanisms
(i.e., If parents show improvements in their interactions
with their children, do these changes account for
improvements in child anxiety?). Indeed, in one of the few
studies to assess the mediating role of parenting found that
parental intrusiveness appeared to mediate treatment
effects such that reductions in parental intrusiveness were
associated with lower child anxiety (Wood et al. 2009).
Finally, in light of the literature on sibling relationship
quality showing that impaired sibling relationships are
associated with increased child anxiety and conversely that
a positive sibling relationship is protective, future research
is needed to explore how siblings can be constructively
involved in the treatment of anxiety disorders in children.
Prevention of Anxiety Disorders in Children
Given the success of psychosocial treatment approaches for
childhood anxiety disorders, research on prevention has
begun to emerge (e.g., Dadds et al. 1997; Ginsburg 2009;
Rapee et al. 2005). Approaches to preventive can be
classified into universal, indicated, and targeted models
(Mrazek and Haggerty 1994). Universal interventions are
delivered to an entire population regardless of risk status,
indicated interventions are delivered to those with elevated
symptoms or early signs of disease, and selective interventions are aimed at persons who are at high risk for
illness based on known risk factors (e.g., parental psychopathology). Within the field of child anxiety, the
majority of research has employed universal or indicated
approaches that do not necessarily involve family members. However, two promising programs of research that
focus on family-based approaches have recently been
published and are presented here of examples of this work.
Rapee et al. (2005; Kennedy et al. 2009) conducted two
RCTs aimed at preventing the onset of anxiety disorders in
young children (ages 3–5 years old) who qualify as
behaviorally inhibited (based on questionnaire and/or laboratory measures). In their brief 6–8 session group intervention for parents, they focused on educating parents
about the nature of anxiety, reducing overprotective parenting, the importance of parents modeling competence
and reducing parental anxiety (the second trial included
parents with an anxiety disorder), the practice of gradual
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exposure, and discussion of high-risk periods, such as the
commencement of school. Findings showed that children
receiving the intervention had fewer anxiety disorders at a
12-month follow-up assessment (Rapee et al. 2005; Kennedy et al. 2009).
Ginsburg (2009) developed a selective intervention to
prevent the onset of anxiety disorders in children. In the
child anxiety prevention study (CAPS), children with
anxious parents were recruited from the community and
randomized to either an 8 session prevention or a wait-list
(WL) control (N = 40). The prevention was modeled after
FCBT and included psychoeducation, relaxation training,
gradual exposure, cognitive restructuring (for both parent
and child), reducing anxiety-enhancing parenting behaviors, contingency management (to reward ‘‘brave’’ behaviors and use extinction techniques to reduce avoidant
behaviors), strategies to recognize and reduce parental
anxiety levels, and enhancement of specific problemsolving and communication skills in the family. At 1-year
follow-up 30% of the children in the WL group developed
an anxiety disorder, compared to 0% in the prevention
group. These findings suggest that family-based prevention
of anxiety in a high-risk sample is promising. A larger
scale evaluation of the CAPS program is currently
underway.
Limitations and Future Directions
The greatest challenge facing the field of prevention of
child anxiety disorders lies in understanding when, how,
and to whom interventions should be delivered, particularly
in light of limited financial resources allocated toward
prevention. Most extant studies have been school-based,
universal interventions that can be costly and often target
those who are not at risk. Thus, addressing these questions
will likely yield more cost-effective interventions that have
a greater impact. Research and development is needed to
determine the ideal format for intervention delivery. For
instance, preventive interventions delivered on the internet
or via printed material, as opposed to therapist-delivered
interventions with individual families, may be more costeffective and yield similar results. Indeed, many bibliotherapy and web-based treatment studies for child and adult
anxiety disorders have found positive results (e.g., Khanna
and Kendall 2010; Leong et al. 2009; Rapee et al. 2006).
Finally, though preventive interventions have demonstrated
success in reducing anxiety symptoms and/or the onset of
anxiety disorders, few have examined other aspects of
functioning (e.g., academic outcomes), and, similar to
treatment studies, few have examined moderators or
mediators of prevention effects. All these issues await
further study.
Clin Child Fam Psychol Rev (2012) 15:144–162
Summary and Conclusions
Over the past two decades, a number of biological and
environmental risk factors have been implicated in the
etiology and maintenance of child anxiety disorders. Specifically, children, particularly those who may have a
genetic or temperamental vulnerability, who are reared in
environments characterized by negative parenting behaviors and patterns of adverse familial interactions are at
higher risk for developing anxiety disorders. The interactive associations (including gene-environment interactions)
among these familial influences are far from understood,
and studies designed to disentangle the complex pathways,
including tests of mediational/moderational models, will
provide critical insight into the development of child
anxiety disorders. To the extent that future studies address
these clinical and methodological issues, the next two
decades should be as fruitful as the past two, and exciting
advances will emerge to help the millions of children and
families who struggle with excessive anxiety.
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